What If a Flu Like 1918's Broke Out Now?

By AVI SALZMAN

Published: March 23, 2008

Correction Appended

WHEN an outbreak of the Spanish flu spread worldwide in 1918, a doctor in Newark advised his patients that they could cure their illness with red onions and coffee. In Atlantic City, the authorities closed amusement parks and theaters indefinitely. And in upstate New York, public health officials distributed a poster warning people against ''careless spitting, coughing, sneezing.''

Those precautions had mixed results, and an estimated 675,000 Americans died during that outbreak, according to the Centers for Disease Control and Prevention in Atlanta.

Today, New Jersey, Connecticut and New York are much more prepared than they were 90 years ago in the event that an influenza outbreak turns into a pandemic. But five years after an avian flu outbreak in Asia made pandemic flu planning a priority, some experts are concerned that states have not been equally vigilant about preparing, and as attention and federal financing begin to decrease, they fear that preparedness efforts will slacken.

''There is a worry that there was a lot more attention to the issue two or three years ago,'' said Richard Hamburg, government relations director for Trust for America's Health, a Washington-based nonprofit health watchdog. ''The fact is that it's still spreading. There are still cases throughout the world. Preparedness is not a one-shot deal. You don't know if this will hit this year, next year, five years, 10 years from now.''

Federal officials are tracking the flu worldwide, but it is up to cities and states to prepare their own public health plans. So in 2002, when fears of a new pandemic began to escalate, the federal government agreed to send the states billions of dollars to prepare for a pandemic. The health and human services secretary, Michael O. Leavitt, warned states in 2005 that if they expected the federal government to bail them out when a pandemic hit, they would be ''tragically wrong.''

Trust for America's Health released a report late last year examining how states were preparing for public health emergencies. The report graded the states on their efforts to protect against a pandemic. Thirty-seven states scored 8 or higher on a scale of 1 to 10, and the lowest score given to any state was 6.

In this region, Connecticut received a score of 8; the state lost points for failing to buy enough antivirals and failing to use a disease surveillance system that is compatible with the federal system to track the progress of an outbreak as it moves across the country. New York scored a 9 -- for failing to increase public health financing as quickly as inflation, though state officials said financing has since risen -- and New Jersey received a 10.

Pandemics occur when the flu virus mutates into a more deadly form and begins to spread easily from person to person. Health officials are worried about pandemic flu now because they fear the avian flu that has spread to Asia and Europe could mutate into a more deadly and transmissible form.

During the 1918 flu pandemic, which killed about 50 million worldwide, the federal government did not ask states to report their flu tallies until weeks or months after the disease had begun to spread. This time around, the government has been tracking the flu for years.

And in 1918, scientists were unable to make an effective vaccine; in an outbreak today, a vaccine could most likely be created within six months.

Connecticut, New Jersey and New York expect to use two basic methods to keep the flu under control before the vaccine is ready: antiviral drugs and a kind of mass crowd control. The federal government has bought 50 million courses of antiviral drugs that federal officials said could limit the severity of flu infections and possibly serve to protect uninfected people from the disease.

The Department of Health and Human Services has urged states to buy antivirals through a discount program that offers a federal subsidy, cutting the cost of a course of drugs (enough for one person) to $20 from $80, said Dr. William F. Raub, science adviser to Secretary Leavitt. The eventual goal is to have enough antiviral medication to cover at least one-fourth of the population.

In the region, the states have taken different approaches to stockpiling antivirals. Connecticut decided not to buy its full share of antivirals, though it has bought about 11,000 courses with federal money and sent a letter to the federal government indicating it wants to buy 8,465 more. Even after including the 520,000 courses in the federal stockpile designated for Connecticut, the state would still have only enough antivirals for about one-sixth of its population.

William Gerrish, a spokesman for the Connecticut Department of Public Health, said state officials haven't put as much emphasis or money into antivirals as other states because they have ''limited utility and limited shelf life.''

Indeed, federal officials are uncertain just how effective antivirals would be in the event of a pandemic and whether they could serve some prophylactic purpose. And because antivirals currently have a five-year shelf life, states are spending millions of dollars on medicine they may have to throw away in the next few years. But other state officials said they weren't willing to take chances.

''If you had a novel strain causing a pandemic that was responsive to antivirals and your state had no stockpile, I could predict that the public would be pretty upset,'' said Dr. Eddy Bresnitz, the state epidemiologist in New Jersey, which has bought 850,000 of the 900,000 courses available under the federal cost-sharing program. He acknowledged, however, that if the antivirals expire, ''that's a lot of dollars flushed down the drain.''

Similarly, New York has gone so far as to buy supplies of antiviral medications that were initially designated for other states that decided not to buy them.

The bulk of the planning, however, has focused on other methods to keep people from getting sick during a pandemic, ranging from surveillance to shutting down public gatherings and schools to quarantining people who are exposed to the flu and isolating those who have it.

The states have held drills for public health and safety workers to determine what to do when the flu hits, and they have developed increasingly sophisticated reporting systems that make doctors pick up the telephone immediately after seeing signs of certain diseases.

New Jersey has been particularly diligent: the state compiles analyses of school absenteeism and flu diagnoses each week and links to its pandemic flu plans from the top of its Web site. The challenge, state officials say, is keeping their plans current and local officials up to date on flu preparedness.

Meanwhile, state officials said they have received less money for outreach to local communities that they have done in the past. Congress turned down the president's request for $870 million in this year's budget for flu preparedness, and state officials said they expected future grants to be much more competitive.

''It means the system is a little bit thinner,'' said Dr. Gus Birkhead, New York's deputy commissioner for public health.

Correction: March 30, 2008

Because of an editing error, an article last Sunday about preparations for a flu pandemic included outdated rankings on emergency-preparedness given to states last year by Trust for America's Health, a Washington-based nonprofit health watchdog group. Thirty-seven states scored 8 or higher on a scale of 1 to 10, and the lowest score given to any state was 6. More than half the states did not receive a score of 5 or lower last year. (Those rankings were from a 2005 report.)

PHOTOS: PLANS: Above, Dr. Eddy Bresnitz, New Jersey's epidemiologist. Left, victims of the 1918 influenza outbreak in Kansas. (PHOTOGRAPHS BY LAURA FREDRICK FOR THE NEW YORK TIMES; NATIONAL MUSEUM OF HEALTH AND MEDICINE) (pg.LI3)